Drug Site-of-Service Program Updates

The drug site-of-service medical policy requires prior authorization for medications given in a hospital-based outpatient setting. Effective October 3, 2025, this policy will expand to include drugs in the table below.

These drugs will continue to require review for medical necessity and the site-of-service authorization is done at the same time a drug is reviewed for medical necessity.

Infusions/injections for the drugs are covered in the most appropriate, safe, and cost-effective locale for each patient. The preferred infusion sites include:

• Infusion center
• Physician’s office
• Patient’s home by a home infusion agency.

Some subcutaneous (SC) injections may be available only at an infusion center or a physician’s office.
 

View the drug site-of-service policy.

For these drugs, infusion or injection in a hospital-based outpatient setting is considered medically necessary only in the following situations:

• The patient has a clinical condition which puts them at increased risk of complications for infusions, including any of the following:
  • Known cardiac or pulmonary conditions that may increase the risk of an adverse reaction.
  • Unstable renal function which decreases the ability to respond to fluid.
  • Difficult or unstable vascular access.
  • Acute mental status changes or cognitive conditions that impact the safety of infusion therapy.
  • Known history of severe adverse drug reactions and/or anaphylaxis to prior treatment with a related or similar drug.
• For the first 90 days for the initial course of infusion/injection of a pharmacologic or biologic agent.
• No outpatient infusion center within 50 miles of the patient’s home and there is no contracted home infusion agency that will travel to the home.